Appendix 4 – Business Angels Ecosystem’s Partner Entities Form

Information regarding the Form:

  1. The Form should be prepared as a file forming an integral part of the Tender.
  2. For each of the entities presented in the Form, an appropriate profile should be selected for the purpose of description, accordingly:
  3. Business Angel Network – Model Form A.
  4. Business Angel Syndicate – Model Form B.
  5. Business Angel – Model Form C.
  6. The Partner Entities presented in the Form are additionally obligated to sign a form of Declaration of Intent to Cooperate, adequate to the profile selected from among the options presented in point 2 a)-c).
  7. For each Partner Entity presented by the Tenderer in the Form, it is necessary to complete all fields which are contained in this appendix, in the tables provided in Model Forms A-C. The tables should be multiplied in order to present profiles of additional entities planned to be engaged in the activities of the Financial Intermediary.
  8. The format in which the information is to be delivered in the appendix is limited to text only (with no additional images, tables, diagrams, links to websites, etc.).
  9. Editorial requirements regarding the text:
  10. document size: A4,
  11. font: Calibri,
  12. basic font size: 11 pt minimum,
  13. line spacing: 1.15 minimum.
  14. No limit is imposed on the maximum volume (in pages) of the Form.
  15. Appropriate rows of this Form can be multiplied (copied), if the fields provided in this Form are insufficient to provide the required information.
  16. Any terms not defined herein shall have the meaning assigned to them in the Rules.

Model Form A

Profile of the Partner Business Angel Network (BAN)
Full name of the BAN
Address of registered office / Phone number / Website address
and e-mail address
Name of register/record / Number of entry in the register/record / Identification number
for tax purposes
Year of establishment and description of the ownership structure of the BAN
Organizational structure and financing model of the activities of the BAN (e.g. from commission or from members’ contributions)
Actions and activities of the BAN over the last 3 years in the area of stimulation and development of investment activities of Business Angels
Requirements to be satisfied by a Business Angel to become a member of the BAN
Number of Business Angel members
in the BAN / Number of active[1] Angel members in the BAN / Number of Angels who joined the BAN in the last 12 months / Number of Angels who left the BAN in the last 12 months
Approximate value of liquid assets available to the Business Angel members of the BAN
Co-investment transactions conducted by the BAN[2]
Full name of the undertaking whom the transaction concerned / Sector and business profile of the undertaking (investment target),
including a description of innovation (if applicable) / Development stage of the undertaking
at the time of the investment / Form of investment / Date and amount of co-investment / Date and amount obtained from divestment (exit) / Investment exit path
[3]
Role and description of activities of the BAN in the scope of stimulating the co-investment process, entry, building value, and/or exit from the above mentioned investments
Authentication of the information on the involvement of the BAN in the presented transaction
(e.g. by providing contact details to key representatives of the undertaking being the subject of the co-investment or co-investors involved)

Partner Business Angel Network's Declaration of Intent to Cooperate

______
First name and surname of the person authorized to represent the Business Angels Network
______
Function of the signatory of this Form in the organizational structure of the Business Angels Network
______
Signature of the person authorized to represent the Business Angels Network
______
Date, place

On behalf of [….][4] (hereinafter as "BAN"), I declare the Business Angel Network's intent to cooperate with […][5], who is a Tenderer in the call for Financial Intermediaries announced by PFR Biznest FIZ as part of the project: "Business Angels’ Group Investments in SMEs – Biznest" ("Biznest Project"), and I declare that:

1.1I am authorized to represent the BAN and to submit declarations in the name of and on behalf of the BAN, which I confirm with the attached document in the form of […][6]

1.2The BAN cooperated/cooperates/intends to[7] cooperate with the Tenderer in the scope of finding Business Angels members of the BAN for particular investments in SMEs made as co-investments with the Financial Intermediary, who will receive financing from PFR Biznest FIZ as a result of selection of the Tenderer's tender in the Biznest Project;

1.3The BAN is familiar with the terms of selecting Financial Intermediaries in the call organized by PFR Biznest FIZ, as well as the provisions of the Tenderer's investment policy and accepts the above rules as binding as they pertain to investments in SMEs;

1.4I confirm that this declaration has been submitted with the knowledge and consent of the members of the BAN, who indicated a preliminary willingness to make Co-investments with the Financial Intermediary, who will receive financing from PFR Biznest FIZ as a result of selection of the Tenderer's tender in the Biznest Project;

1.5I acknowledge that Business Angels who are to make the investment together with the Financial Intermediary managed by the Tenderer/the Tenderer have to act with integrity as well as have an investment track record and good reputation on the market;

1.6I consent to the verification of the data indicated in this Form by PFR Biznest FIZ, PFR Ventures or their advisors and I undertake to provide the abovementioned entities with the data and information necessary to conduct such a verification;

1.7I consent to the disclosure by PFR Ventures and/or PFR Starter FIZ, at any time, of information about me, received by PFR Ventures and/or PFR Starter FIZ in connection with the Tender, to entities belonging to the capital group of which PFR Ventures and/or PFR Starter FIZ is a member, as well as to TFI BGK and Bank GospodarstwaKrajowego, and the competent ministry responsible for the management of the SG OP (the managing institution).

1.8I consent to the processing of my personal data contained in this form by PFR Ventures and/or PFR Starter FIZ and by other authorized entities for purposes related to the analysis of the Tender, in compliance with the Act of 29 August 1997 on the protection of personal data (Journal of Laws No. 133, item 883).

______

Signature

Model Form B

Profile of the Partner Business Angel Syndicate (Business Angel Syndicate)[8]
Full name of the Syndicate
Address of registered office / Phone number / E-mail address
Name of register/record / Number of entry in the register/record / Identification number
for tax purposes
Approximate value of Liquid Assets which the members of the Business Angel Syndicate can allocate for co-investments within the Investment Horizon assumed in the Tender
Year of establishment and description of the ownership structure of theBusiness Angel Syndicate
Brief description of the Syndicate's form of activity and its investment profile
Data of the Business Angel members of the Business Angel Syndicate[9]
Business Angel 1
First name and surname / Series and number of ID card or passport number / Phone number
A summary resume, including in particular investment and/or entrepreneurial experience
Co-investment transactions conducted by the Business Angel Syndicate
Full name of the undertaking whom the transaction concerned / Sector and business profile of the undertaking (investment target),
including a description of innovation (if applicable) / Undertaking development stage at the time of the investment / Form of investment / Date and amount of co-investment / Date and amount obtained from divestment (exit) / Investment exit path
[10]
Angels indicated in the Form as members of the Syndicate, who financially participated in the transaction
Role and description of the Syndicate's activities in the process of building value of the project
Authentication of information about the presented transaction
(e.g. by providing contact details to key representatives of the undertaking being the subject of the co-investment)

Business Angel Syndicate's Declaration of Intent to Cooperate[11]

______
First name and surname of the person authorized to represent the Business Angel Syndicate
______
Function of the signatory of this Form in the organizational structure of the Business Angels Syndicate
______
First name and surname of the person authorized to represent the Business Angel Syndicate
______
Date, place

On behalf of [….][12] (hereinafter as "Business Angel Syndicate"), I declare the Business Angel Syndicate's intent to cooperate with […][13], who is a Tenderer in the call for Financial Intermediaries announced by PFR Biznest FIZ as part of the project: "Business Angels’ Group Investments in SMEs – Biznest" ("Biznest Project"), and I declare that:

1.1I am authorized to represent the BAS and to submit declarations in the name of and on behalf of the BAS, which I confirm with the attached document in the form of […][14]

1.2The Business Angel Syndicate cooperates/intends to[15] cooperate with the Tenderer in the scope of finding Business Angels members of the Business Angel Syndicate for particular investments in SMEs made as co-investments with the Financial Intermediary, who will receive financing from PFR Biznest FIZ as a result of selection of the Tenderer's tender in the Biznest Project;

1.3The Business Angel Syndicate is familiar with the terms of selecting Financial Intermediaries in the call organized by PFR Biznest FIZ as well as the provisions of the Tenderer's investment policy and accepts the above rules as binding as they pertain to investments in SMEs;

1.4I confirm that this declaration has been submitted with the knowledge and consent of the members of the Business Angel Syndicate, who indicated a preliminary willingness to make Co-investments with the Financial Intermediary, who will receive financing from PFR Biznest FIZ as a result of selection of the Tenderer's tender in the Biznest Project;

1.5I acknowledge that Business Angels who are to make the investment together with the Financial Intermediary managed by the Tenderer/the Tenderer have to act with integrity as well as have an investment track record and good reputation on the market;

1.6I consent to the verification of the data indicated in this Form by PFR Biznest FIZ, PFR Ventures or their advisors and I undertake to provide the above mentioned entities with the data and information necessary to conduct such a verification;

1.7I consent to the disclosure by PFR Ventures and/or PFR Starter FIZ, at any time, of information the Business Angel Syndicate received by PFR Ventures and/or PFR Starter FIZ in connection with the Tender, to entities belonging to the capital group of which PFR Ventures and/or PFR Starter FIZ is a member, and to TFI BGK and Bank GospodarstwaKrajowego, and the competent ministry responsible for the management of the SG OP (the managing institution).

1.8I consent to the processing of my personal data contained in this form by PFR Ventures and/or PFR Starter FIZ and by other authorized entities for purposes related to the analysis of the Tender, in compliance with the Act of 29 August 1997 on the protection of personal data (Journal of Laws No. 133, item 883).

______

Signature

Model form C

Partner Business Angel Profile
First name and surname / Series and number of ID card or passport number / Phone number
Approximate value of Liquid Financial Assets available to the Business Angel
Approximate value of Liquid Assets which the Business Angel can allocate for co-investment within the Investment Horizon assumed in the Tender
Form of investment activity (e.g. independently, as a natural person, or through its own investment vehicle)
A summary resume, including in particular investment and/or industry experience
Investment transactions conducted by the Business Angel
Full name of the undertaking whom the transaction was concerned / Sector and business profile of the undertaking (investment target),
including a description of innovativeness / Undertaking development stage at the time of the investment / Form of investment / Date and amount of co-investment / Date and amount obtained from divestment (exit) / Investment exit path
[16]
Role and description of activities of the Business Angel in the process of building value of the project
Authentication of information about the presented transaction
(e.g. by providing contact details to key representatives of the undertaking being the subject of the co-investment)

Partner Business Angel's Declaration of Intent to Cooperate

______
First name and surname of the Business Angel
______
Signature of the Business Angels
______
Date, place

I, the undersigned, hereby represent that:

1.1.I am familiar with the terms of selecting Financial Intermediaries in the call organized by PFR Biznest FIZ related to the execution of the project: "Business Angels’ Group Investments in SMEs – Biznest" ("Biznest Project"), as well as the provisions of the investment policy of the […][17] ("Tenderer"), and I accept the above rules as binding as they pertain to future investments which I will make together with the Financial Intermediary;

1.2.I declare my intent to cooperate with the Tenderer in making investments in investment projects together with the Financial Intermediary established/selected as a result of the call conducted by FR Biznest FIZ and the selection of the Tenderer's tender in the Biznest Project;

1.3.I have full legal capacity and I have no legal constrains in relation to submitting this declaration;

1.4.I have the financial capacity to make at least one co-investment with the Financial Intermediary selected/established as a result of selection of the Tenderer's tender;

1.5.I acknowledge that the funds I earmarked for financing investments together with the Financial Intermediary must originate from my own funds and cannot be in any way encumbered and must be free from any public support and/or state aid, and in particular they cannot constitute public funds within the meaning of the Act of 27 August 2009 on public finance.

1.6.My funds earmarked for financing investments together with the Financial Intermediary cannot violate any provisions of the Act of 16 November 2000 on preventing money laundering and financing terrorism (i.e. Journal Laws of 2016, item 299, as amended), including in particular the making of a private contribution in the declared amount does not constitute money laundering or serve the purposes of financing terrorism;

1.7.I declare that no conflict of interest arises for me due to any of the reasons specified in §13.1 of the Rules and I undertake to immediately inform PFR Ventures of any circumstances which constitute a conflict of interest causing a conflict of interest, if it occurs;

1.8.I am aware that the financial support provided by PFR Starter FIZ represents state aid and is subject, in particular, insofar as its allocation and settlement is concerned, to the provisions of the Act of 30 April 2004 on the procedural issues concerning state aid (Journal of Laws of 2007, No. 59, item 404, as amended), and therefore I acknowledge that upon entering into the Co-investment Agreement I will have the status of a state aid beneficiary;

1.9.I consent to the disclosure by PFR Ventures and/or PFR Starter FIZ, at any time, of information about me, received by PFR Ventures and/or PFR Starter FIZ in connection with the Tender, to entities belonging to the capital group of which PFR Ventures and/or PFR Starter FIZ is a member, and to TFI BGK and Bank GospodarstwaKrajowego, and the competent ministry responsible for the management of the SG OP (the managing institution).

1.10.I consent to the processing of my personal data contained in this declaration by PFR Ventures and/or PFR Starter FIZ and by other authorized entities for purposes related to the analysis of the Tender, in compliance with the Act of 29 August 1997 on the protection of personal data (Journal of Laws No. 133, item 883).

______

Podpis

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[1] An active Angel means a Business Angle who made at least one equity investment in SME in the minimum amount of PLN 50,000, in the past 24 months (from the date of submission of a Tender by a Tenderer).

[2] With particular reference to transactions conducted during the period of the last 3 years from the date of submission of a Tender

[3] Lines concerning co-investment projects in which the BAN was involved should be multiplied according to the Tenderer’s requirements regarding the description.

[4] Enter the name of the Business Angels Network which declares its cooperation

[5] Enter the Tenderer's details

[6] Enter the data of the document which authorizes the person submitting the declaration to represent the Business Angel Network. The document should be attached to the declaration.

[7]Delete as appropriate

[8] A special purpose vehicle / An investment vehicle under which a fixed group of two or more Business Angels makes investments.

[9] Lines concerning particular Business Angels involved in the Syndicate should be multiplied according to the Tenderer’s requirement regarding the description.

[10] Lines concerning co-investment projects in which the Syndicate was involved should be multiplied according to the Tenderer’s requirement regarding the description.

[11]The Declaration should be signed by each of the representatives of the Partner Business Angel Syndicate – in this case, the table contained in the Declaration should be multiplied according to the number of members of the Partner Syndicate.

[12] Enter the name of the Business Angels Syndicate which declares its cooperation

[13] Enter the Tenderer's details

[14] Enter the data of the document which authorizes the person submitting the declaration to represent the Business Angel Network. The document should be attached to the declaration.

[15]Delete as appropriate

[16] Lines concerning investment projects in which a Business Angel was involved should be multiplied according to the Tenderer’s requirement regarding the description.

[17] Enter the Tenderer's details.